Preventing deaths and harm from misplaced nasogastric tubes: long term results of radiographer-led pathway
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All Authors
Razak, Sairah
Roe, Gillian
Tolan, Damian
LTHT Author
Razak, Sairah
Roe, Gillian
Tolan, Damian
Roe, Gillian
Tolan, Damian
LTHT Department
Radiology
Non Medic
Advanced Radiographic Practitioner
Publication Date
2025
Item Type
Conference Abstract
Language
Subject
Subject Headings
Abstract
Aims: To evaluate whether radiographer identification and action for misplaced nasogastric (NG) feeding tubes prevent patient harm and deaths in a multisite tertiary centre.
Methods: Healthcare systems cause death and harm from feeding into misplaced nasogastric tubes. Service transformation was triggered by 4 adverse events in a 762-day period in our Trust encompassing 2,500 beds related to NG xray (NGXR) interpretation and miscommunication. Radiographers were trained to provide immediate NGXR interpretation and take action to remove or arrange repositioning for misplaced NG. Continuous surveillance of NG adverse events and radiographer NGXR interpretation accuracy were evaluated for 4,953 days after implementation in a service performing 10,000 NG placements per annum.
Results: Trained radiographer NGXR evaluation and action on misplaced tubes prevented any episodes of harm after pathway implementation (0 events in 4953 days vs 4 events in 762 days). Pathway change reduced NGXR requesting (preintervention 75% vs 9.3% post) with increased first line pH testing of gastric aspirate (pre intervention pH 12% vs 84%). Accuracy of NGXR position compared with radiologist review was 99%.
Conclusion: Radiographer training and empowerment to immediately evaluate and act on NGXR findings produced sustained prevention of patient harm, reduced NGXR requesting and improved pathway compliance. This should serve as a basis for a national patient safety programme. We propose an achievable NGXR accuracy standard over 95% in a large trained radiographer workforce.